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ℹ️ A red asterisk (*) indicates a required field.

All other fields are optional. Please provide all requested information if possible, but these fields may be left blank.

Do not provide complainant Personally Identifiable Information (PII) such as Social Security numbers or dates of birth anywhere in this form.

Name*

Email*

Age*

Address*

Suite/Apt./Mail Stop

City*

Country*

State*

Zip Code/Route*

Is this on behalf of a business that was targeted by a Cyber incident?

Yes No

Did you send or lose money in the incident?*

Yes No

Transaction Type*

Was the money sent or lost?*

Yes No

Transaction Amount*

Transaction Date*

Did you contact your bank, financial institution, or cryptocurrency exchange?

Yes No

Recipient Bank Address

Recipient Bank Suite/Mail Stop

Recipient Bank City

Recipient Bank Country

Recipient Bank State

Recipient Bank Zip Code/Route

Describe what happened in your own words. Provide any information you have yet to include in this complaint that may assist law enforcement in understanding what happened.*

Please provide any technical details regarding this incident. This can include email headers, cryptocurrency transaction metadata, ransomware hashes, etc.

Are there any other witnesses or persons affected by this incident?

If you have reported this incident to other law enforcement or government agencies, please provide the name, phone number, email, date reported, report number, etc.

Is this an update to a previously filed complaint?

Yes No

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature. I affirm that the information I provided is true and accurate to the best of my knowledge. I understand that providing false information could make me subject to fine, imprisonment, or both. (Title 18, U.S.Code, Section 1001)*

I agree

Digital Signature*

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